Important Reminders:
Humana Policies and Processes

Humana has a wide range of policies and procedures to help provide services to its members and support to its network physicians. Here is a review of some of the key policy areas that affect Humana-contracted physicians.

Utilization management (UM)
The utilization management program plays a key role in guiding Humana members, network providers and customers to a more satisfying health benefit experience. Es importante que los médicos, otros proveedores de la atención de la salud y sus pacientes entiendan estos hechos:

• Humana uses nationally recognized clinical criteria as guidelines for all utilization review determinations and the existence of coverage.
• Humana does not reward health care providers for denying service or care.
• Los incentivos financieros nunca son parte de una decisión de la UM.

Physicians can obtain a copy of specific UM criteria from their local market office upon request.

Clinical practice guidelines
Clinical practice guidelines are available on the provider area of Humana’s Web site at www.humana.com. Click on “Providers” on the left side of the home page, and then click on “Provider Resource Center.” Then select “Provider Tools” on the left. Click on “Clinical Tools,” “Clinical Practice Information,” and choose from the list of available clinical practice guidelines.

The specific links will take you from the Humana Web site to the Web site of the organization that issued the guidelines. For example, the link for clinical practice guidelines on childhood immunizations will take you to the Web site for the American Academy of Pediatrics. Paper copies of the guidelines may also be requested from your local market office.

Disease management (DM)
Humana offers several disease-specific programs for complex, chronic conditions. These programs are designed to extend the services of the physician and empower the member through education and support. Information about available DM programs and procedures for accessing services are available on Humana’s Web site at www.humana.com. Click on “Providers” on the left side of the home page, and then “Provider Resource Center.” Then select “Provider Tools” on the left. Click on “Clinical Tools,” and then click on “Clinical Services and Innovation” to view a list of links to specific DM programs.

Adverse determinations/denial decisions
The attending physician or primary care physician (PCP) has the opportunity to have a peer-to-peer conversation with a Humana regional medical director or pharmacist reviewer to discuss a possible adverse determination or a denial decision. These conversations can be scheduled by calling the local market office or by calling the number given in the denial notification letter. In cases when another opinion may be needed, an External Review Organization (ERO) board-certified specialist may be asked to review the case.

Urgent/emergent services
Covered members have access to urgent/emergent services for screening and stabilization 24 hours a day, seven days a week, in or out of the service area if the member perceives that an emergency situation exists per the “prudent layperson” standard. This means that a person with average knowledge of health services and medicine, acting reasonably, would have believed an emergency existed. No referral or authorization is required for emergency visits.

Quality Improvement (QI) program
Humana has a comprehensive Quality Improvement program, which encompasses clinical care, preventive care and administrative functions of the health plan. Physicians can obtain a written QI program description by contacting Humana Customer Service at 1-800-4-HUMANA (1-800-448-6262). For a progress report
of how goals are being met in individual markets, mail a request to the following address:

Lynn Lee
Humana
Progress Report
201 West Main, RVS 2
Louisville, KY 40202

Members’ rights and responsibilities
All commercial and Medicare Humana members have certain rights and responsibilities when being treated by Humana-contracted physicians, and these rights are outlined in Humana’s Rights and Responsibilities statement. Los médicos pueden encontrar una copia de la declaración de su Manual de Administración del Médico (PAM, por sus siglas en inglés) y en paquetes informativos para nuevos médicos.

Humana asks that participating physicians display a copy of the Humana (both commercial and Medicare) Members’ Rights and Responsibilities statement in their offices to remind members and physicians of their complementary roles in maintaining a productive relationship.

Medical record audits
Humana conducts medical record audits in randomly selected physician offices to monitor and improve record-keeping practices. The minimum passing score is 85 percent with a performance goal of 90 percent. A Web source for obtaining documentation guidelines can be found in the Physician Administration Manual (PAM).

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